@extends('user.base')
@section('content-header','Create Patient')
@section('content-body')
<section  class="content">
	<!--Display detailed patient information-->
	<div class="container col-md-9 col-xs-9">
		<form class="form-horizontal" action="{{ URL('patient/info/')}}" method="post" accept-charset="utf-8">
			<input type="hidden" name="_token" value="{{ csrf_token()}}">
			<input type="hidden" name="_method" value="POST">
			<div class="form-group">
				<label class="control-label col-md-4 ">First Name:</label>
				<div class="col-md-6">
					<input class="form-control " type="text" name="firstname" value="" placeholder="Enter patient's' first name here" required="required">
				</div>
			</div>
			<div class="form-group">
				<label class="control-label col-md-4">Last Name:</label>
				<div class="col-md-6">
					<input class="form-control" type="text" name="lastname" value="" placeholder="Enter patient's last name here" required="required">
				</div>
			</div>
			<div class="form-group ">
				<label class="control-label col-md-4">Check No.</label>
				<div class="col-md-6">
					<input class="form-control" type="text" name="checkNumber" value="" placeholder="Enter check no. here.">
				</div>
			</div>
			<div class="form-group">
				<label class="control-label col-md-4">Age:</label>
				<div class="col-md-6">
					<input class="form-control" type="number" name="age" value="" placeholder="" max="99" mix="0" step="1" required="required">
				</div>
			</div>
			<div class="form-group">
				<label class="control-label col-md-4">Sex:</label>
				<label class="radio-inline">
					<input  id="radioMale" type="radio" name="sex" value="male" placeholder="" >
					Male
				</label>
				<label class="radio-inline">
					<input id="radioFemale" type="radio" name="sex" value="female" placeholder="">
					Female
				</label>
			</div>
			<div class="form-group">
				<label class="control-label col-md-4">Contact:</label>
				<div class="col-md-6">
					<input class="form-control" type="tel" name="contact" value="" placeholder="Enter patient contact number here.">
				</div>
			</div>
			<div class="form-group">
				<label class="control-label col-md-4">Address:</label>
				<div class="col-md-6">
					<input type="text" class="form-control" name="address" value="" placeholder="Enter patient address here.">
				</div>
			</div>
			<div class="form-group">
				<label class="control-label col-md-4">Description:</label>
				<div class="col-md-6">
					<textarea class="form-control" rows="5" placeholder="Brief patient description" name="description">						
					</textarea>
				</div>
			</div>
			<div class="form-group">
				<div class="col-md-6 col-md-offset-4">
					<button class="btn btn-success form-control">
						OK
					</button>
				</div>
			</div>
		</form>
	</div>
</section>
@endsection
@section('css')
@endsection
@section('js')
<script type="text/javascript">$(".datepicker").datepicker({
	todayBtn: "linked"
});</script>
@endsection